CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2015

4/25/2015
CMS HOSPITAL CONDITIONS OF
PARTICIPATION (COPS) 2015
Discharge Planning Standards and Final
Worksheet
Speaker
 Sue Dill Calloway RN, Esq.
CPHRM, CCMSCP
 AD, BA, BSN, MSN, JD
 President of Patient Safety and
Education Consulting
 Board Member
Emergency Medicine Patient Safety Foundation
 614 791-1468
(Call with questions, No emails)
 [email protected]
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You Don’t Want One of These
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The Conditions of Participation (CoPs)
 Regulations first published in 1986
 CoP manual updated more frequently now
 Tag numbers are section numbers and go from
0001 to 1164
 First regulations are published in the Federal
Register then CMS publishes the Interpretive
Guidelines and some have survey procedures
2
 Hospitals should check the CMS Survey and
Certification website once a month for changes
1www.gpoaccess.gov/fr/index.html
2www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp
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Location of CMS Hospital CoP Manuals
CMS Hospital CoP Manuals new address
www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc.pdf
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CoP Manual also Called SOM
www.cms.hhs.gov/manu
als/downloads/som107_
Appendixtoc.pdf
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CMS Survey and Certification Website
www.cms.gov/SurveyCertific
ationGenInfo/PMSR/list.asp#
TopOfPage
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Transmittals
www.cms.gov/Transmittals/01_overview.asp
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Access to Hospital Complaint Data
 CMS issued Survey and Certification memo on
March 22, 2013 regarding access to hospital
complaint data
 Includes acute care and CAH hospitals
 Does not include the plan of correction but can request
 Questions to [email protected]
 This is the CMS 2567 deficiency data and lists the
tag numbers
 Updated quarterly
 Available under downloads on the hospital website at www.cms.gov
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Access to Hospital Complaint Data
 There is a list that includes the hospital’s name and
the different tag numbers that were found to be out
of compliance
 Many on restraints and seclusion, EMTALA, infection
control, patient rights including consent, advance
directives and grievances
 Two websites by private entities also publish the
CMS nursing home survey data and hospitals
 The ProPublica website
 The Association for Health Care Journalist (AHCJ)
websites
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Access to Hospital Complaint Data
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Updated Deficiency Data Reports
www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/Hospitals.html
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Deficiency Data Discharge Planning
Tag
Number
Section
Nov 2014 Jan 2014
799
Discharge Planning (DP)
25
20
800
DP Evaluation
52
25
806
DP Needs Assessment
69
58
807
Qualified DP Staff
10
8
810
Timely DP Evaluation
14
12
14
Deficiency Data Discharge Planning
Tag
Section
Nov 2014 Jan 2014
811
Documentation & Evaluation
21
16
812
Discharge Planning
4
3
817
818
Discharge Plan
DP Personnel
Removed 28
4
0
819
MD Required DP
4
3
820
Implementation of DP
73
53
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Deficiency Data Discharge Planning
Tag
Section
Nov 2014
Jan 2014
821
Reassess DP
141
49
823
List of HH Agencies
38
31
837
Transfer or Referral
50
38
843
Reassess DP Process
31
Total 536
30
Total 364
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CMS Discharge Planning
Standards
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Discharge Planning Memo
 CMS issues 39 page memo on May 17, 2013 and final
transmittal July 19, 2013 and in current manual
 Revises discharge planning standards
 Includes advisory practices to promote better patient
outcomes
 Only suggestions and will not cite hospitals
 Call blue boxes
 The discharge planning CoPs have been reorganized
 A number of tags were eliminated
 The prior 24 standards have been consolidated into 13
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Discharge Planning Revisions
www.cms.gov/SurveyCertificati
onGenInfo/PMSR/list.asp#Top
OfPage
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Discharge Planning Transmittal July 19, 2013
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Starts at Tag Number 799
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Discharge Planning 799
7-19-2013
 Standard: The hospital must have a discharge
planning (DP) process that applies to all patients
(799)
 The hospital must have written DP P&Ps (799)
 To determine if will need post hospital services like home
health, LTC, assisted living, hospice etc.
 To determine what patient will need for safe transition to
home
 Called transition planning or community care transition
 Need to incorporate new research on care transitions to
prevent unnecessary readmissions
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Discharge Planning 799
Discharge planning is:
 New DP guidelines based on this new research
 It is a shared responsibility of health professionals and
facilities
 Hospital needs adequate resources to prevent
readmissions
 1 in 5 patients readmitted within 30 days (20%)
– Reduced to 17% in 2015
 1 in 3 patients readmitted within 60 days (34%)
 Good DP will help patient reach goal of plan of care after
discharge
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Discharge Planning 799
 CMS says the DP process is in effect for all patients
 However, CMS notes that the preamble made it
clear it was meant to apply to inpatients and not
outpatients
 DP presupposes hospital admission
 CMS suggests that hospitals voluntarily have an
abbreviated post-hospital DP for same day surgery,
observation, and certain ED patients
 However, remember that all patients have a right to have
a plan of care and be involved in the plan of care
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Discharge Planning (DP) 799
 Hospital must take steps to ensure DP P&P are
implemented consistently
 DP based on 4 stage DP process:
 Screen all patients to determine if patient at risk such as
screening questions by nursing admission assessment
 Evaluate post-discharge needs of patients
 Develop DP if indicated by the evaluation or requested
by patient or physician
– Consider putting it in written patient rights
 Initiate discharge plan prior to discharge of inpatient
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Discharge Planning P&P 799
 Suggests input from MS, board, home health
agencies (HH), long term care facilities (LTC),
primary care physicians, clinics, and others
regarding the DP P&Ps
 Involve the patient in the development of the
plan of care
 Must actively involve patients through out the
discharge process
 Patient have the right to refuse and if so CMS
recommends this be documented
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Identify Patients in Need of DP 800
 Standard: The hospital must identify at an early
stage all patients who are likely to suffer adverse
consequences if no DP is done
 Recommend all inpatients have a Discharge Plan
– Most hospitals the nurse asks specific questions on the
admission assessment
 If not must have P&P and document criteria and
screening process used to identify who is likely to
need DP
 Hospital must identify which staff are responsible are
carrying out the evaluation to identify if patient needs DP
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Case Management Consults
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Identify Patients in Need of DP 800
 CMS says factors the assessment should include:
 Patient’s functional status and cognitive ability
 Type of post hospital care patient needs
 Availability of the post hospital needed services
 Availability of the patient or family and friends to
provide follow up care in the home
 No national tool to do this
 Blue box advisory recommendation to do a
discharge plan on all every inpatient
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Nurses Admission Assessment
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Functional Assessment
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Blue Box Advisory Do a DP on all Inpatients
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Discharge Planning 800
 Must do at least 48 hours in advance of discharge
 If patient’s stay is less than 48 hours then must make sure
DP is done before patient’s discharge
 Must make sure no evidence that patient’s
discharge was delayed due to hospital’s failure to
do DP
 DP P&Ps must state how staff will become aware of
any changes in the patient’s condition
 Change may require developing DP for the patient
 If patient is transferred must still include information
on post hospital needs
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DP Survey Procedure
800
 Surveyor to go to every inpatient unit to make sure
timely screening to determine if DP is needed
 Unless hospital does DP evaluation for all patients
 CMS instructs the surveyors to conduct discharge
tracers on open and closed inpatient records
 Can hospital demonstrate there is evidence of DP if
the stay is less than 48 hours
 Was criteria and screening process for DP
evaluation applied correctly
 Was there process to update the discharge plan?
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So What’s in Your P&P?
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Discharge Planning Evaluation 806
 Standard: The hospital must provide a DP
evaluation to patients at risk, or as requested by the
patient or doctor
 Must include the likelihood of needing post hospital
services

Like home health, hospice, RT, rehab, nutritional consult,
dialysis, supplies, meals on wheels, transport,
housekeeping, or LTC
 Is the patient going to need any special equipment (walker,
BS commode, etc.) or modifications to the home
 Must include an assessment if the patient can do self
care or others can do the care
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Discharge Planning Evaluation 806
 Must have process for making patients or their
representative aware they can request a DP
evaluation
 Put it in writing in the patient rights document
 Have the nurse inform the patient and document it in the
admission assessment
 Must have a process for making sure physicians are
aware they can request a DP evaluation
 Unless hospital does DP evaluation on every patient
 Issue memo to physicians, include in orientation book for
new physician orientation, and discuss at MEC meeting
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Discharge Planning Evaluation 806
 Must evaluate if patient can return to their home
 If from a LTC, hospice, assisted living then is the
patient able to return
 Hospitals are expected to have knowledge of
capabilities of the LTC and Medical homes and
services provided
 May need to coordinate with insurers and Medicaid
 Discuss ability to pay out of pocket expenses
 Expected to have know about community resources
 Such as Aging and Disability Resources or Center for Independent
Living
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Discharge Planning Evaluation 806
Discharge evaluation is more detailed in
contrast to the screening process
Used to identify the specific areas to address
in the discharge plan
Must evaluate if patient can do any self-care
Or family or friends
The goal is to return the patient back to the
setting they came from and to assess if they
can return
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Discharge Evaluation & Plan
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Discharge Evaluation & Plan 806
 Will the patient need PT, OT, RT, hospice, home
health care, palliative care, nutritional consultation,
dietary supplements, equipment, meals, shopping,
housekeeping, transport, home modification, follow
up appointment with PCP or surgeon, wound care
etc.
– Discuss if patient can pay out of pocket expenses
 Make sure if sent to LTC it does not exceed their
care capabilities
 Hospitals are required to have knowledge of the
capabilities of the LTC facilities and community services
available including Medicaid home
44
CMS DP Checklist for Patients
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CMS Your Discharge Planning Checklist
www.medicare.gov/Publications/Pu
bs/pdf/11376.pdf
46
47
www.ahrq.gov/patients-consumers/diagnosistreatment/hospitals-clinics/goinghome/goinghomeguide.pdf
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www.patientsafety.org/page/transtoolkit/
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Discharge Evaluation & Plan 806
 Patient has a right to participate in the development
and implementation of their plan of care
 CMS views discharge planning as part of the plan of
care (POC)
 The patient is expected to be actively engaged in
the development of the discharge evaluation
 Surveyor will make sure staff are following DP policies
and procedures
 If hospital does not do one on every inpatient will
assess how to determine if change in the patient’s
condition
50
Survey Procedure 806
 Will check to make sure documented in the medical
record
 If from assisted living or LTC is there documentation
facility has capability to provide necessary care?
 Surveyor will assess if patient needs special
medical equipment or modifications to the home
 Surveyor will assess to make sure the patient or
other can provide the needed care at home
 Will assess if insurance coverage would or would
not pay for necessary services
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Qualified Person to Do DP 807
 Standard: A RN, social worker (SW), or other
appropriately qualified person must develop or
supervise the development of the DP evaluation
 Written P&P must say who is qualified to
discharge planning evaluation
 P&P must also specify the qualifications for staff
other than RNs and SWs
 All must have knowledge of clinical, social,
insurance, financial and physical factors to meet
patient’s post discharge needs
52
Multidisciplinary Team Approach
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Discharge Planning
 Standard: the DP evaluation must be completed
timely to avoid unnecessary delays (810)
 This means there has to be sufficient time after
completion for post-hospital care to be made
 Cannot delay the discharge
 Expects to be started within 24 hours of request or need
 Standard: The hospital must discuss the results of
the DP evaluation with the patient (811)
 Documentation of the communication must be in the
medical record
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Discharge Planning
 Standard: The hospital must discuss the results
of the DP evaluation with the patient (811,
continued)
 Do not have to have the patient sign the document
 Cannot present the evaluation as a finished product
without participation of the patient
 Standard: The DP evaluation must be in the
medical record (812)
 Must be in the medical record to guide the development of
the discharge plan
 Serves to facilitate communication among team members
55
Discharge Planning
Standard: RN, SW, or other qualified person
must develop the discharge plan if the DP
evaluation indicates it is needed (818)
 DP is part of the plan of care
 Best if interdisciplinary such as case manager,
dietician, pharmacist, respiratory therapy, PT, OT,
nursing, MS, etc.
Standard: The physician may request a DP if
hospital does not determine it is needed (819)
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Implement the Discharge Plan 820
 Standard: The hospital must implement the
discharge plan
 Patient and family counseled to prepare them for posthospital care
 This include patient education for self care
 It includes arranging referral to HH or hospice
 It includes arranging transfers to LTC, rehab hospitals
etc.
 Arrange for follow up appointments, equipment etc.
 Patient needs clear instructions for any problems that
arise, who to call, when to seek emergency assistance
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Implement the Discharge Plan 820
 Recommendations to reduce readmissions:
 Improved education on diet, medication, treatment,
expected symptoms
 Use teach back or repeat back
 Legible and written discharge instructions and may use
checklists
 Written in plain language (issue of low health literacy)
 Provide supplies for changing dressings on wounds
 Give list of all medication with changes (reconciled)
 Document the above
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Survey Procedure 820
 Send necessary medical information (like discharge
summary) to providers that the patient was referred
to prior to the first post-discharge appointment or
within 7 days of discharge, whichever comes first
 Surveyor will make sure referrals made to
community based resources such as Department of
Aging, elder services, transportation services,
Centers for Independent Living, Aging and Disability
Resource Centers, etc.
 If transfer, will make sure medical record
information sent along with patient
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Reassess the Discharge Plan
821
Standard: The hospital must reassess the
discharge plan if factors affect the plan (821)
 Changes can warrant adjustments to the discharge
plan
 Have a system in place for routine reassessment of
all plans
 Many hospitals now have discharge planners or
social workers who review the charts on a daily basis
 If this is not done then need system to find out when
there are changes
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Freedom of Choice LTC HH 823
 Standard: If patient needs HH or LTC must
provide patients a list (823)
 Must inform the patient or family of their freedom to
chose
 Cannot specify or limit qualified providers
 Must document that the list was provided
 If in managed care organization, must indicate which ones
have contracts with the MCO
 Disclose if hospital has any financial interest
 If unable to make preference must document why such as
no beds available
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Transfer or Referral 837
 Standard: Hospital must transfer or refer patients to
the appropriate facility or agency for follow up care
(837)
 Includes hospice, LTC, mental health, dialysis, HH,
suppliers of durable medical equipment, suppliers of
physical and occupational therapy etc.
 Could be referral for meals on wheels,
transportation or other services
 Must send necessary medical record information
 Includes information necessary for transfer
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Reassessment
843
 Standard: The hospital must reassess if DP
process is on an on-going basis and review the
discharge plans to ensure they meet the patient’s
needs
 Must track readmissions
– Must choose at least one interval to track such as 7, 15, 30
days and review at least 10% of preventable readmissions
– Recommend 30 days as the NQF endorsed readmission
measures
 Must review P&P to make sure DP is ongoing on at least
a quarterly basis
 Must track effectiveness of DP process through QAPI
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Memo Includes Cross Walk to Old Tags
67
Additional Resources
 There are two additional resources
 Tips based on the literature to reduce
unnecessary readmissions
 CMS has a discharge planning worksheet
–The 3 CMS worksheets are very important
–Will be used in 2014 for surveys including
validation surveys with some modification
–It is imperative that all hospitals be familiar with
the discharge planning worksheet
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CMS Worksheet
Discharge Planning
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CMS Hospital Worksheets History
 First, October 14, 2011 CMS issues a 137 page memo in
the survey and certification section and it was pilot tested in
hospitals in 11 states
 Memo discusses surveyor worksheets for hospitals by CMS during a
hospital survey
 Addresses discharge planning, infection control, and
QAPI (performance improvement)
 May 18, 2012 CMS published a second revised edition and
pilot tested each of the 3 in every state over summer 2012
 November 9, 2012 CMS issued the third revised worksheet
and revised discharge planning one March 2014
 Final ones issued November 26, 2014
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Final 3 Worksheets QAPI
www.cms.gov/SurveyCertificationG
enInfo/PMSR/list.asp#TopOfPage
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CMS Hospital Worksheets
 Hospitals should be familiar with the three
worksheets and discharge planning is 15 pages
 Will use whenever a validation survey or
certification survey is done at a hospital by CMS
 CMS says worksheets are used by State and
federal surveyors on all survey activity in
assessing compliance with any of the three CoPs
 Hospitals are encouraged by CMS to use the
worksheet as part of their self assessment tools
which can help promote quality and patient safety
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CMS Hospital Worksheets
 And of course completing the forms helps the
hospital to comply with those three CoPs
 Citation instructions are provided on each of the
worksheets
 The surveyors will follow standard procedures when
non-compliance is identified in hospitals
 This includes documentation on the Form CMS
2567
 Not used in CAH but good tool for CAH to use
 Questions to: [email protected]
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Form 2567 Statement of Deficiency/POC
www.cms.gov/Medicare/CMSForms/CMSForms/Downloads/CMS2567.pdf
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CMS Hospital Worksheets
 Some of the questions asked might not be apparent
from a reading of the CoPs
 So the worksheets are a good communication
device
 It helps to clearly communicate to hospitals what is
going to be asked in these 3 important areas
 Hospitals might want to consider putting together a
team to review the 3 worksheets and complete the
form in advance as a self assessment
 Hospitals should consider attaching the
documentation and P&P to the worksheet
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CMS Hospital Worksheets
 This would impress the surveyor when they came to
the hospital
 The worksheet is used in new hospitals undergoing
an initial review and hospitals that are not
accredited who are suppose to have a CMS survey
every three or so years
 The Joint Commission (TJC), American Osteopathic
Association (AOA) Healthcare Facility Accreditation Program,
CIHQ, (Center for Improvement in Healthcare Quality) or DNV
Healthcare are the 4 AOs with deemed status
 It would also be used for hospitals undergoing a
validation survey by CMS
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Final Discharge Planning Evaluation Tool
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CMS Hospital Worksheets Goals
 Goal is to reduce hospital acquired conditions
(HACs) including healthcare associated infections
 Goal to prevent unnecessary readmission and
currently 1 out of every 5 Medicare patients is
readmitted within 30 days (17% in 2015)
 Many hospitals financially penalized after October
1, 2012 because they had a higher than average
rate of readmissions
 2,610 hospitals forfeited 428 million in 2015
 The underlying CoPs on which the worksheet is
based did not change
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CMS Hospital Worksheets
 First part of the risk evaluation tool includes
identification information and is 15 pages
 Called the Hospital Patient Safety Initiative or PSI
 Name of the state survey agency which in most
states is the department of health under contract by
CMS
 In Kentucky it is the OIG or Office of Inspector
General
 It will ask for the name and address of the
hospital, CCN number, and date of the survey
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Discharge Planning Worksheet P&P
 Is there a discharge planning process for certain
categories of outpatients such as observation, ED
patients and same day surgery patients?
 Could add questions to the assessment tool and
include in questions asked in pre-admission tests for
OP surgery
 Are discharge P&P in effect for all inpatients?
 Is there evidence on every unit that there is
discharge planning activities?
 Are staff following the discharge planning P&P?
– Tag 800, 806, and 818
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Discharge Planning P&P
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Are Staff Aware of Your DP Policy?
83
84
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What’s In Your Policy and Procedure?
85
Discharge Planning Worksheet 2.4
 For patients not initially identified as in need of
discharge plan, does the P&P address for updating
this based on changes in a patient’s condition? (800)
 Many hospitals have the nurse doing the
admission assessment ask a set of predetermined
questions to see if assistance is needed
 How do you update this when there is a change?
 Note that hospital in which case managers and nurse
discharge planners see the patients or review their
charts everyday to make sure there is no change in
condition, this will stream line the process and ensure
compliance
86
Nurses Admission Assessment
87
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88
Functional Assessment
89
Discharge Planning Worksheet 2.4
 Are the inpatient unit staff aware of how, when,
and whom to notify of such changes in order to
trigger a discharge planning evaluation? (Tag 800)
 An example would be a patient who is expected to
go home in the morning and develops a pulmonary
emboli and condition changes
 Do the nurses on the unit pick up the phone and call
the RN discharge planners or social workers so
they know there is a change in the condition and
perhaps now they need a discharge planning
evaluation done
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Discharge Evaluation & Plan
91
Discharge Planning Evaluation 2.5
 The following questions are asked for a patient who
does not have a discharge planning evaluation
 Does hospital have a process for notifying patients
they can request a discharge planning evaluation?
 Or process for the patient representative to request (806)
 Note that hospitals should consider putting this in their
written patient rights
 Don’t just hand it to the patient but rather have the
registration person tell the patient about this right
 Note hospitals could also mention this during the
nursing admission assessment and document it
92
Give Patients A Copy of Their Rights
93
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CMS Discharge Planning Medicare Learning
www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/Discharge-Planning-Booklet-ICN908184.pdf
94
Discharge Planning Worksheet 2.5
 Can the hospital show that they conducted the DP
evaluation upon request? (806)
 Can both the discharge planning and unit nursing
staff describe the process for the patient or the
patient’s representative to request a discharge
planning evaluation
 They must be able to do this even if the hospital’s
screening criteria did not indicate that one was
needed (Tag 806)
 Surveyor is suppose to interview the patient to
make sure they knew how to request one
95
Discharge Planning Worksheet 2.5
Will interview doctors and make sure they
know they can request a discharge planning
evaluation (806 and 819)
If doctor not aware will also ask for evidence
of how hospital informs the medical staff
about this
Again, if the hospital does an DP evaluation
on every inpatient this section will not be
applicable and the hospital avoids jumping
through many of the hoops
96
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Physicians Can Request a DP Evaluation
Note that the hospital could include this
information in new physician orientation
Note the Chief Medical Officer could write a
memo to all physicians and advise that they
can request a DP evaluation
Best way is to place on order in the medical
record
This only has to be done if the hospital does
not do a DP evaluation on all patients
97
Discharge Planning Evaluation CMS MLN
98
Discharge Planning Worksheet
 Will ask staff to describe the process for
physicians to order a discharge plan (819)
 Does P&P provide a process for ongoing
reassessment of discharge plan in case of
changes to the patient’s condition (819)?
 Does hospital discharge planning P&P include a
process for ongoing reassessment of the
discharge plan based on changes in the patient’s
condition, changes in available support including
changes in post hospital care requirements? (821)
99
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100
Section 3 QAPI DP and Reassessment
Does hospital review discharge planning
process on an ongoing manner as through
PI?
Does hospital track readmission rates as part
of discharge planning? (843 and 283)
 Does assessment include if readmission was
potentially preventable?
 If preventable then did the hospital make
changes to the planning process?
101
QAPI
102
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Discharge Planning Worksheet
Does hospital track readmission rates as part
of discharge planning? (843 and 283)
Consider asking patient why they thought
readmission occurs
Remember study that reduced
readmissions if appointment made within 14 days after discharge
The study found that the timing of the visit
was very important
103
Timing of Physician Follow Up Appt
 Timing of the physician follow up appointment may
be important
 One hospital found if patient saw doctor day 1-4 the
chance of readmission is less than 6%
 If appointment 6-10 days after discharge readmission
rate was 6 to 13%
 If visits on day 25 then chance went up to 29%
 Readmission rate increased 1% for every day between
discharge and the first physician visit
 Article published Jan 8, 2014, Detroit Medical Center,
Media Health Leaders
104
Discharge Planning Worksheet
Does hospital collect feedback from postacute providers for effectiveness of the
hospital’s discharge planning process?
 This would include places like LTC, assisted
living or home health agencies
 Consider holding monthly meetings with the
home health agencies and long term care
facility staff
 Note recent study that found doing this can
reduce readmissions by 20%
105
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Monthly Meetings LTC and HH
 Hospitals should consider working with their state
QIO
 JAMA study found that hospitals working with QIOs in
communities across the country experienced twice the
reduction in readmissions compared with those that did
not (Jan 23, 2013)
 Consider holding monthly meeting with your various
partners such as nursing homes and home health
staff
 One study showed this reduced readmissions by
20.8% (Jan 2014 IPRO-NY’s QIO)
106
Discharge Planning Tracers
Has a discharge planning tracer Section 4
 Surveyors is to review five patient records
 One inpatient who has DP evaluation and
discharge plan under development
 Surveyor is to review the closed medical record
of two or three patients who was discharged with
DP evaluation and discharge plan
 Will try and include one patient who was
readmitted within 30 days
107
108
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4/25/2015
Discharge Planning Tracers
 Will mark worksheet to show if it was an open
medical record where the patient is still in the
hospital or
 A closed medical record where the patient has
been discharge
 Should include a combination of patient’s admitted
from home as well as from LTC, assisted living, or
other residential healthcare facility
 Don’t include review of medical records of patients
transferred to another acute care hospital
109
Discharge Planning Tracers 4.3
 Was the screening done to identify if the inpatient
needed a discharge planning evaluation? (800)
 Includes at the time of admission, after an admission but
at least 48 hours prior to discharge, or N/A
 In some hospitals all patients get a discharge plan
 Can staff demonstrate that the hospital’s criteria
and screening process for discharge evaluation
were correctly applied (800)?
 Was discharge planning evaluation done by
qualified person (SW, RN) as defined in the P&P?
(807 evaluation or 818 plan)
110
DP by Qualified Staff
111
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4/25/2015
Discharge Planning Tracers
 Are the results of the discharge planning evaluation
documented in the chart? (812)
 Did the evaluation include an assessment of the
patients post-discharge care needs?
 Examples:
 Patient need home health referral
 Patient needs bedside commode
 Patient needs home oxygen
 Patient needs post hospital physical therapy
 Meals on wheels, etc.
112
Discharge Planning Tracers
 Did the evaluation include an assessment of: (806)
 Patient’s ability to perform ADL (feeding, personal
hygiene, ambulation, dressing, bladder control
etc.)?
 Family support or patient ability to do self care?
 Whether patient will need specialized medical
equipment or modifications to their home?
 Is support person or family able to meet the
patient’s needs and assessment of community
resources ?
113
Discharge Planning Tracers
 Did the evaluation include an assessment of: (806)
 Was patient given a list of HHA or LTC facilities in the
community and must be documented in the record and
the list appropriate (806)
 If the hospital provided the list were the facilities
geographically appropriate for the patient (823)
 An example would be selection of a LTC facility that is
close to the patient’s home
 One hospital has patient sign an attestation about freedom
of choice and include information on community resources
and LTC and home health compare
114
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4/25/2015
DP Evaluation Includes an Assessment
115
116
Discharge Planning Tracers To LTC
 Separate set of questions if patient admitted from
LTC or assisted living
 Did evaluation include if LTC has capacity for patient to go
back there?
 Does it include assessment if insurance coverage will
cover it if they go back there? (806)
 Was the discharge planning evaluation timely to allow for
arrangements if the patient needs to go back there (810)
 Was the patient’s representative involved in these
discussions? (811 and patient rights 130)
 Discharge plan needs to match the patient’s needs (811,
130) and any changes in condition were documented (821)
117
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If Admitted From a LTC or Other Facility
118
Discharge Plan
 Did the discharge plan match the needs of the
patient as determined by the discharge planning
evaluation? (818)
 If there were any significant changes in the patient’s
condition was it documented in the medical record
and was the discharge planned updated to reflect
this? (821)
119
Discharge Plan
120
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Discharge Planning Tracers
 If patient discharged home is their initial
implementation of the discharge plan?
 Did staff provide training to patient including
recognized methods such as teach back, repeat
back, or simulation labs?
 Were the written discharge instructions legible and
use non-technical language (low health literacy)
 Was a list of all medication patient will take after
discharge given with a clear indication of any
changes?
 TJC has 5 EPs on medication reconciliation NPSG.03.06.01
121
Medication List From RED
122
Project RED Tools
Revised 2013
www.bu.edu/famm
ed/projectred/
123
41
4/25/2015
www.ahrq.gov/professionals/systems/h
http://www.ahrq.gov/professionals/syst
ems/hospital/red
ospital/red/
124
Discharge Planning Tracers
 Will look for evidence of hospital of patients and
support persons on admission and discharge
 Was patient referred back for follow up with their
PCP or a health center?
 Was there a referral to PT, mental health, HHA,
hospice, OT etc. as needed?
 Was there a referral for community based resources
such as transportation services, Department of Aging,
elder services, transport services etc.?
 Arranged for needed equipment such as oxygen,
commode, wheel chair etc.
125
126
42
4/25/2015
Discharge Planning Worksheet
 If transferred to another inpatient facility was the
discharge summary ready and sent with patient?
 The following controversial section was changed in
the final revision
 Was discharge summary sent before first postdischarge appointment or within 7 days of discharge?
 Was follow up appointment scheduled?
 Now says send necessary medical record
information to providers the patient was referred
prior to the first post-discharge appointment or 7
days, whichever comes first (820)
127
Appointments for Follow Up
128
Discharge Summary in the Hands of PCP
129
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Discharge Planning Worksheet Transfers
 Was the necessary medical record information
ready at the time of transfer if patient sent to
another facility (837)
 Note CMS has requirements for the transfer form
 Was there any part of the discharge plan that the
hospital failed to implement that resulted in a delay
in discharge (820)
 Was there documentation in the medical record of
results of tests pending at the time of discharge
both to the patient and the post hospital provider?
 Was patient readmitted within 30 days?
130
131
Were Any of the Following Done?
 Were any of the following services initiated while
patient was in the hospital:
 Scheduled follow up appoint,
 Filled prescription
 Pharmacist met with patient or family
 Pharmacist reviewed discharge medications prior to
discharge
 Home setting visited by hospital staff
 Discharge planning checklist given to patient such as
CMS, AHRQ, CAPA checklist
132
44
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CMS DP Checklist for Patients
133
CMS Discharge Checklist
 CMS website recommends the discharge planning
team use a checklist to make transfer more efficient
 It is available at www.medicare.gov
 Previously research showed the value of hospital
discharge planners using a discharge checklist
 We need to dictate the discharge summary
immediately when the patient is discharged
 We need to document that it is in the hands of the
family physician
134
CMS Your Discharge Planning Checklist
www.medicare.gov/Publications/Pu
bs/pdf/11376.pdf
135
45
4/25/2015
136
www.ahrq.gov/patients-consumers/diagnosistreatment/hospitals-clinics/goinghome/goinghomeguide.pdf
137
www.patientsafety.org/page/transtoolkit/
138
46
4/25/2015
Readmission and Pending Tests Results
 Is there documentation in the medical record that if
there are pending tests at the time of discharge that
the patient and or post hospital provider were
informed?
 Example would be to include information in written
discharge summary and include in the patient’s written
discharge instructions
 See the RED form
 Is the inpatient admission record review to
determine if a patient was readmitted within 30
days?
139
Outstanding Labs or Tests
140
The End! Questions???
 Sue Dill Calloway RN, Esq.
CPHRM, CCMSCP
 AD, BA, BSN, MSN, JD
 President of Patient Safety and
Education Consulting
 Board Member
Emergency
Medicine Patient Safety Foundation
 614 791-1468
(Call with questions, No emails)
 [email protected]
 Additional resources on how to reduce unnecessary
readmissions
141
47
4/25/2015
How to Prevent Unnecessary
Readmission and Important
Discharge Information
142
Readmission Rates Vary
 Readmission rates vary widely in the US
 Too often quality of care during transition from
hospital to home is not good
 Data shows readmission rate for MI and CHF vary
 Found only modest association between
performance on discharge measures and patient
readmission rates
 See A. K. Jha, E. J. Orav, and A. M. Epstein, Preventing
Readmissions with Improved Hospital Discharge Planning,
NEJM Dec 31, 2009 361 (27):2637-2645
143
Readmissions and Discharges
 One in 5 hospital discharges (20%) is complicated
by adverse event within 30 days
 20% were readmitted within 30 days with 1/3 leading to
disability which was reduced in 2015 to 17%
 Often leads to visits to the ED and rehospitalization
 6% of these patients had preventable adverse
events
 66% were adverse drug events
 The incidence and severity of adverse events affecting patients
after discharge from the hospital. Forster AJ, Murff HJ,
Peterson JF, Gandhi TK, Bates DW. Ann Intern Med.
2003;138:161-167
144
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4/25/2015
AHA Guide to Reduce Avoidable Readmissions
 AHA had committees look at the issue of how to
reduce unnecessary hospital readmissions
 AHA published several memos and a 2010 Health
Care Leader Guide to Reduce Avoidable
Readmissions
 Issues memo on Sept 2009 on Reducing
Avoidable Hospital Readmissions
 Includes evaluation of post acute transition
process which is the process of moving from the
hospital to home or other settings
145
AHA Guide to Reduce Readmissions
www.hret.org/care/projects/guid
e-to-reduce-readmissions.shtml
146
Free Readmission Newsletter
Readmissions eNewsletter
[[email protected]]
147
49
4/25/2015
CMS Discharge Checklist
 CMS website recommends the discharge planning
team use a checklist to make transfer more efficient
 It is available at www.medicare.gov
 Previously research showed the value of hospital
discharge planners using a discharge checklist
 We need to dictate the discharge summary
immediately when the patient is discharged
 We need to document that it is in the hands of the
family physician
148
CMS Your Discharge Planning Checklist
www.medicare.gov/Publications/Pu
bs/pdf/11376.pdf
149
CMS
 Discharge planners should be a member of the
hospital committee to prevent unnecessary
readmissions
 Discharge planners and transition coaches may
actually make the physician appointments
 Ensure medication information is clearly understood
by the patients and use pharmacists when needed
in the process
 CMS discharging planning standards start at tag
number 799
150
50
4/25/2015
Things to Consider
 Form a committee on redesigning the discharge process
 Do a literature search and pull articles
 Look at the different transition studies that have been
done and which ones have been successful
 Care Transition, Transition of Care, RED, RED 2, Guided care,
H2H, IHI Transforming Care at the Bedside, STAAR, Boost,
GRACE, Interact, Evercare, etc.
 Have physician dictate discharge summary as soon as
patient is discharge
 Hospitals needs to get it into the hands of the primary
care physician and document this in the chart
151
Things to Consider
 Medical staff should dictate what needs to be in the
discharge summary beyond what CMS and TJC
require
 Hospital should schedule all follow up appointments
with practitioners for the patients
 Hospital should put in writing for the patient and in
the discharge summary
 Any tests that are pending that are not back yet
 Any future tests and these should be scheduled before the
patient leaves the hospital
152
Things to Consider
 Use a discharge checklist for staff to use
 Pa Patient Safety Authority has one called “Care at
Discharge” at
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/Pages/home.aspx
 Society of Hospital Medicine has one at
www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Tools&Template=/CM/
ContentDisplay.cfm&ContentID=8363
 Give patients a copy of the CMS checklist “Your
Discharge Planning Checklist” at
www.medicare.gov/Publications/Pubs/pdf/11376.pdf
 Give a list of medications with times and reason for
taking
153
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PaPSA Checklist
154
See Society of Hospital Medicine at
http://www.hospitalmedicine.org/AM/Template.cfm?
Section=Quality_Improvement_Tools&Template=/CM
/ContentDisplay.cfm&ContentID=8363
155
Things to Consider
 Ensure education on all new meds and use teach
back to ensure education and give information in
writing
 Ensure patient is given a copy of the plan of care
 Give patient in writing their diagnosis and written
information about their diagnosis
 Have patient repeat back in 30 seconds
understanding of their discharge instructions
 Includes symptoms that if they occur what you want
to do and who to call
156
52
4/25/2015
Things to Consider
 Call back all patients discharged and review information
and reinforce discharge instructions
 Have a call back number that patients and families can
use 24 hours a day, seven days a week
 Reconciling the discharge plan with national guidelines
and critical pathways when relevant
 Assess your hospital’s readmission rate
 Pull charts and review for any patient who is readmitted
within 30 days
 Have prescriptions filled in advance and brought to
hospital to go over at discharge
157
Project RED Tools
Revised 2013
www.bu.edu/famm
ed/projectred/
158
www.ahrq.gov/professionals/systems/h
http://www.ahrq.gov/professionals/syst
ems/hospital/red
ospital/red/
159
53
4/25/2015
Outstanding Labs or Tests
160
Appointments for Follow Up
161
Medication List
162
54
4/25/2015
The End! Questions???
 Sue Dill Calloway RN, Esq.
CPHRM, CCMSCP
 AD, BA, BSN, MSN, JD
 President of Patient Safety and
Education Consulting
 Board Member
Emergency Medicine Patient Safety
Foundation at www.empsf.org
 614 791-1468
 [email protected]
163
55